<?php require_once ("header.php");?>


<script type="text/javascript" src="jscripts/view.js"></script>
<body id="form" >
	
	<div id="form_container">

	<form id="form_159998"  class="appnitro"  method="post" action="org_registration_submit.php">
		<div class="form_description">	
			<h2>Organization Registration</h2>
			<p>Register your Organization with us.</p>
		</div>						
			<ul >
			
					<li id="li_10" >

		<label class="description" for="lblUserName">Username: </label>
		<div>
			<input id="userNameID" name="userName" class="element text medium" type="text" maxlength="255" value=""/> 
		</div><p class="guidelines" id="userNameGuide"><small>Select a User Name for Hestia</small></p> 
		</li>		<li id="li_11" >
		<label class="description" for="lblPassword">Password: </label>
		<div>
			<input id="passwordID" name="password" class="element text medium" type="password" maxlength="255" value=""/> 
		</div><p class="guidelines" id="passwordGuide"><small>(password guidelines)</small></p> 
		</li>		<li id="li_12" >

		<label class="description" for="lblrePassword">Re-enter your password: </label>
		<div>
			<input id="lblrePassword" name="rePassword" class="element text medium" type="password" maxlength="255" value=""/> 
		</div> 
		</li>		<li id="li_5" >
		<label class="description" for="lblOrganization">Organization Name: </label>
		<div>
			<input id="organizationId" name="organization" class="element text medium" type="text" maxlength="255" value=""/> 
		</div><p class="guidelines" id="orgGuide"><small>What is the name of your organization </small></p> 
		</li>		<li id="li_7" >

		<label class="description" for="cFName">Contact Name: </label>
		<span>
			<input id="cFNameID" name= "cFName" class="element text" maxlength="255" size="8" value=""/>
			<label>First</label>
		</span>
		<span>
			<input id="cLNameID" name= "cLName" class="element text" maxlength="255" size="14" value=""/>
			<label>Last</label>

		</span> 
		</li>		<li id="li_1" >
		<label class="description" for="lblPhoneNumber">Phone: </label>
		<span>
			<input id="areaCode" name="areaCode" class="element text" size="3" maxlength="3" value="" type="text"/> -
			<label for="areaCode">(###)</label>
		</span>
		<span>

			<input id="pnum3" name="pnum3" class="element text" size="3" maxlength="3" value="" type="text"/> -
			<label for="pnum3">###</label>
		</span>
		<span>
	 		<input id="pnum4" name="pnum4" class="element text" size="4" maxlength="4" value="" type="text"/>
			<label for="pnum4">####</label>
		</span>
		 
		</li>		<li id="li_2" >

		<label class="description" for="Address">Address </label>
		
		<div>
			<input id="streetAdd" name="streetAdd" class="element text large" value="" type="text"/>
			<label for="streetAdd">Street Address</label>
		</div>
	
		<div>
			<input id="add2" name="add2" class="element text large" value="" type="text"/>
			<label for="add2">Address Line 2</label>

		</div>
	
		<div class="left">
			<input id="city" name="city" class="element text medium" value="" type="text"/>
			<label for="city">City</label>
		</div>
	
		<div class="right">
			<input id="state" name="state" class="element text medium" value="" type="text"/>
			<label for="state">State</label>

		</div>
	
		<div class="left">
			<input id="zip" name="zip" class="element text medium" maxlength="15" value="" type="text"/>
			<label for="zip">Zip Code</label>
		</div>
	
		
		</li>		<li id="li_3" >

		<label class="description" for="email">Email: </label>
		<div>
			<input id="email" name="email" class="element text medium" type="text" maxlength="255" value=""/> 
		</div> 
		</li>		<li id="li_13" >

		<label class="description" for="webSite">Web Site </label>
		<div>
			<input id="webSite" name="webSite" class="element text medium" type="text" maxlength="255" value="http://"/> 
		</div> 
		</li>		<li id="li_9" >

		<label class="description" for="element_9">Additional Information: </label>
		<div>
			<textarea id="element_9" name="element_9" class="element textarea medium"></textarea> 
		</div> 
		</li>
			
					<li class="buttons">
			    <input type="hidden" name="form_id" value="159998" />
			    
				<input id="saveForm" class="button_text" type="submit" name="submit" value="Submit" />
		</li>

			</ul>
		</form>	
	</div>
	</body>
	<?php include("footer.php"); ?>